1. Mood Disorders and Suicide
Chapter 6
Mood Disorders and Suicide

2. Range of Emotions
A person with a mood disorder experiences emotions that are extreme and, therefore, abnormal.

3. Types of depressive disorders
Major depressive disorder
Dysthymic disorder
Double depression

4. Major Depression: An Overview
Major depressive episode: Overview and defining features
Extremely depressed mood lasting at least two weeks
Cognitive symptoms – feelings of worthlessness, indecisiveness
Disturbed physical functioning (sleep and eating)
Anhedonia – loss of pleasure/interest in usual activities

5. Major Depression: An Overview
Major depressive disorder
Single episode – highly unusual
Recurrent episodes (2 or more major depressive episodes separated by at least 2 months of no depression) – more common
From grief to depression
Pathological or impacted grief reaction

6. Major Depression: An Overview
Major depressive disorder
Mean age is 30
Typical first episode is 4-9 months if untreated

7. Dysthymia: An Overview
Overview and defining features
Symptoms are milder than major depression
Persists for at least two years in adults, one year in children and adolescents
No more than two months symptom free
Symptoms can persist unchanged over long periods (≥ 20 years)
Facts and statistics
Late onset – typically in the early 20s

8. Double Depression: An Overview
Overview and defining features
Major depressive episodes and dysthymic disorder
Dysthymic disorder often develops first
Associated with severe psychopathology and problematic future course
High relates of relapse

9. Types of bipolar disorders
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder

10. The Structure of Mood Disorders
Mania
Hypomanic episode – less severe than manic episode that lasts at least 4 days

11. The Structure of Mood Disorders
Features of a manic episode
Elevated, expansive mood for at least one week
At least 3 of the following:
Inflated self-esteem, decreased need for sleep, excessive talkativeness, flight of ideas or sense that thoughts are racing, easy distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable but risky behaviors
Impairment in normal functioning

12. Bipolar I Disorder: An Overview
Overview and defining features
Alternations between full manic or mixed episodes and (but not necessarily) depressive episodes and/or hypomania
Facts and statistics
Average age of onset is years
Can begin in childhood
Tends to be chronic and acute
Suicide is a common consequence – as high as 48% (usually during depressive episodes)

13. Bipolar II Disorder: An Overview
Overview and defining features
Alternations between major depressive and hypomanic episodes
Facts and statistics
Average age of onset is years
Can begin in childhood
10% to 25% of cases progress to full bipolar I disorder
Tends to be chronic

14. Cyclothymic Disorder: An Overview
Overview and defining features
Milder but more chronic version of bipolar disorder
hypomanic and dysthymic episodes that last a long time
Must last for at least two years (one year for children and adolescents)

15. Cyclothymic Disorder: An Overview
Facts and statistics
Average age of onset is 12 to 14 years
60% are female
chronic and lifelong
1/3 to 1/2 develop bipolar

16. Prevalence of Mood Disorders
Worldwide lifetime prevalence
16% for major depression
Sex differences
Females are twice as likely to have major depression
Bipolar disorders equally affect males and females
1% for bipolar disorder

17. Prevalence of Mood Disorders
Occurs less often in prepubertal children
Rapid rise in adolescence
Adults over 65 have about 50% less than adults
Three-month-olds can show depression
Children below nine do not show classic mania or bipolar symptoms
Mood disorders are often misdiagnosed as ADHD
Children are being diagnosed with bipolar at increasingly high rates

18. Life Span Developmental Influences on Mood Disorders
Depression in elderly between 14% and 42%
Comorbidity with anxiety disorders
Less gender imbalance after 65 years of age
Cultural differences exist
Hopi Native Americans - “Heartbroken”
Native American population - 4 X the rate

19. Mood Disorders: Familial and Genetic Influences
Family studies
Rate is high in first-degree relatives of probands (2-3 x greater)
Relatives of bipolar probands tend to have unipolar depression
Twin studies
Concordance rates are high in identical twins (2-3 x)
Severe mood disorders have strong genetic influence
Heritability rates are higher for females compared to males; 40% women and 20% men for depression

20. Mood Disorders: Familial and Genetic Influences
Twin studies
Vulnerability for unipolar or bipolar disorder
Appears to be inherited separately
Some genetic factors are common for mood and anxiety disorders (not mania though)

21. Mood Disorders: Neurobiological Influences
Neurotransmitter systems
Low Serotonin and its relation to other neurotransmitters causes mood disorders
Permissive hypothesis – when serotonin is low, other neurotransmitters are “permitted” to become dysregulated

22. Mood Disorders: Neurobiological Influences
The endocrine system
Elevated cortisol damages the hippocampus and prevents neurogenesis
Sleep disturbance
Hallmark of most mood disorders
REM and depression
Insomnia and depression linked

23. Mood Disorders: Psychological Dimensions (Stress)
Stressful life events
Stress is strongly related to mood disorders
Poorer response to treatment
Longer time before remission
The relation between context (interpretation) of life events and mood
Reciprocal-gene environment model
Relationship between stress and bipolar is also strong
Stressful life events – 20-50% of people develop a mood disorder
Context of the life event – single mother loses job and can’t support family or Romney
Biggest stressors – humiliation, loss and social rejection
Severe events precede all types of depression except for a small group with melancholic or psychotic features.
Major life stressors is a slightly stronger predictor for initial episodes of depression compared to recurrent episodes.
Reciprocal – gene environment model – certain genes predispose people to experience more stressful life events, such as people who seek out difficult relationships due to personality characteristics. It goes both ways - stress triggers depression and depressed individuals create or seek stressful events.
Bipolar and stress – negative stressful events trigger depression but positive stressful life events triggers mania in vulnerable individuals, such as a new job, promotion, getting married, getting into graduate school.
mania sometimes caused by a loss of sleep, jet lag – something that disturbs the circadian rhythm.

24. Mood Disorders: Psychological Dimensions (Learned Helplessness)
Learned helplessness (LH)- Lack of perceived control over life events
LH and a depressive attributional style
Internal attributions
Negative outcomes are one’s own fault
Stable attributions
Believing future negative outcomes will be one’s fault
Global attribution
Believing negative events will disrupt many life activities

25. Mood Disorders: Psychological Dimensions (Beck’s Cognitive Theory)
Negative coping styles
Depressed persons engage in cognitive errors
Tendency to interpret life events negatively
Types of cognitive errors
Arbitrary inference – overemphasize the negative
Overgeneralization – negatives apply to all situations

26. Mood Disorders: Psychological Dimensions (Cognitive Theory)
Cognitive errors and the depressive cognitive triad
Think negatively about oneself, the world and the future
Negative schema

27. Mood Disorders: Social and Cultural Dimensions
Marital relations
Marital dissatisfaction is strongly related to depression especially in males
Mood disorders in women
Females over males (70:30) except bipolar disorders (50:50)
Gender imbalance likely due to socialization (perceptions of uncontrollability)
Social support
Extent of social support is related to depression and predicts recovery from depression

29. An Integrative Theory Shared biological vulnerability
Overactive neurobiological response to stress
Inadequate coping and depressive cognitive style
Diathesis-stress model
Biological, psychological and social factors all influence the development of mood disorders
Exposure to stress

30. FIGURE 6.5  An integrative model of mood disorders.

31. Treatment of Mood Disorders: Selective Serotonergic Reuptake Inhibitors (SSRIs)
Specifically block reuptake of serotonin
Fluoxetine (Prozac) is the most popular SSRI
SSRIs pose some risk of suicide particularly in teenagers
Negative side effects

32. Treatment of Mood Disorders: Mixed Reuptake Inhibitors
Venlafaxine (Effexor)- blocks norepinephrine as well as serotonin
Nefazodone (Serzone) – improves sleep efficiency
Both have fewer side effects than SSRIs

33. Treatment of Mood Disorders: Monoamine Oxidase (MAO) Inhibitors
Block monoamine oxidase enzyme that breaks down serotonin and norepinephrine
Slightly more effective than tricyclics
Must avoid foods containing tyramine
Examples include beer, red wine, cheese
Many patients do not like the dietary restrictions
MAOIs more effective for depression with atypical features; fewer side effects, but, use less often because:
Eating and drinking foods and beverages containing tyramine, such as cheese, red wine, or beer can lead to high blood pressure and death.
Other drugs including cold medicines are dangerous and fatal in interaction with a MAOI. Therefore only prescribed with other antidepresssants aren’t working.

34. Treatment of Mood Disorders: Tricyclic Antidepressants
Used to be widely used (e.g., Tofranil, Elavil)
Block reuptake
Norepinephrine and other neurotransmitters
Therapeutic effects
Can take two to eight weeks
Negative side effects are common
May be lethal in excessive doses so not good for suicidal tendencies

35. Treatment of Mood Disorders: Lithium
Lithium carbonate is a common salt
Primary drug of choice for bipolar disorders (50% reduction in symptoms)
Can be toxic
Side effects may be severe
Dosage must be carefully monitored
Lithium is a mood-stabilizing drug
Why lithium works remains unclear

36. Treatment of Mood Disorders: Electroconvulsive Therapy (ECT)
ECT is effective for cases of severe depression
The nature of ECT
Involves applying brief electrical current to the brain
Results in temporary seizures
Usually six to 10 outpatient treatments are required
Side effects are few and include short-term memory loss
Uncertain why ECT works
Relapse is common (60%)

37. Psychosocial Treatments
Cognitive-behavioral therapy
Addresses cognitive errors in thinking
Also includes behavioral components
Interpersonal psychotherapy
Identifies stressors and focuses on problematic interpersonal relationships
Prevention
Combined treatments for depression more effective (73% versus 48%)
Prevention relapse of depression
Psychosocial treatments for bipolar

39. The Nature of Suicide: Facts and Statistics
11th leading cause of death in the United States- maybe two to three times higher
Overwhelmingly a white and Native American phenomenon
China and suicide rates (more females)
Suicidal ideation - thinking seriously about suicide
Suicidal plan – formulation of a specific method
Suicidal attempt – person survives

40. The Nature of Suicide: Facts and Statistics
Gender differences
Males are more successful at committing suicide than females
Females attempt suicide more often than males

41. The Nature of Suicide: Risk Factors
Suicide in the family
Low serotonin levels
Preexisting psychological disorder
Alcohol use and abuse
Stressful life event
Past suicidal behavior
Suicide contagion
Treatment

42. Summary of Mood Disorders
All mood disorders share:
Gross deviations in mood
Common biological and psychological vulnerability
Occur in children, adults, and the elderly
Onset, maintenance, and treatment are affected by
Stress
Social support

43. Summary Suicide is an increasing problem
Not unique to mood disorders
Medications and psychotherapy produce comparable results
High rates of relapse

44. DSM-5 Proposed Changes